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Home My WebLink About0352 STARBOARD LANE - Health 352 STARBOARD LANE, OSTERVILLE A= 166 115 o 0 0 d r �. Commonwealth of Massachusetts Title 5 Official Inspection Forms Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 352 Starboard Lane ; Property Address BELEN L CURRAN REVOCABLE TRUST Owner Owner's Name information is Osterville MA 02655 6/7/20. required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any . way. Please see completeness checklist at the end of the form: Important:When Inspector Information A. Ins filling out forms I� on the computer, use only the tab Robert Paolini key to move your Name of Inspector cursor-do not Robert Paolini use the return key. Company Name, jr 67 Tanbark Rd. IL�I Company Address Marstons Mills } MA 02648 City/Town State Zip Code a (508)280-9499 S14454 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section"15.340 of Title 5(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my-,training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation.by the Local Approving Authority i 4. ❑ .Fails 6/7/20 Inspec or's Si n to Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 L Commonwealth of Massachusetts Title 5 Official Inspection Form FI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 352 Starboard Lane Property Address BELEN L CURRAN REVOCABLE TRUST Owner Owner's Name information is required for every Osterville MA 02655 6/7/20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. ' 1) System Passes: .91 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: t 2) System Conditionally Passes: 0 One or more system components'as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements.. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form w Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 352 Starboard Lane Property Address BELEN L CURRAN REVOCABLE TRUST Owner Owner's Name information is Osterville MA 02655 6/7/20 required for every , page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cost.) 2) System Conditionally Passes(cunt.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ -Y ❑ N ❑ ND (Explain below): El The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C 3) Further Evaluation is Required by the Board of Health: , ❑ Conditions exist which require further evaluation by the.Board of Health in order to determine if the'system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ` t5insp.doc•rev.7/26/2018 Tittle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 352 Starboard Lane ' Property Address BELEN L CURRAN REVOCABLE TRUST Owner Owner's Name information is required for every Osterville MA 02655 - 6/7/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cunt.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if.any) . determines that the system'Is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1. of a public water supply. ` . ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water, supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: *" This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached.to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes".or"No".to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged,SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 352 Starboard Lane Property Address BELEN L CURRAN REVOCABLE TRUST Owner Owners Name information is required for every Osterville MA 02655 6/7/20 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1h day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well' ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet,but greater than 50 feet from a private water supply well with no acceptable water quality analysis. IThis system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.W2612018 Title 6 Official Mspection Form:Subsurface Sewage Disposal System-Page 5 of 18 . Commonwealth of Massachusetts Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments u 352 Starboard Lane Property Address BELEN L CURRAN REVOCABLE TRUST Owner Owner's Name information is required for every Osterville )MA 02655 6/7/20 page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304..The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected forrsigns of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with. information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System'(SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection _Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 352 Starboard Lane Property Address BELEN L CURRAN REVOCABLE TRUST Owner Owner's Name information is required for every Osterville MA 02655 6/7/20 page. City/Town State Zip Code. Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ -Yes ® No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): . Detail: Sump pump? ❑ Yes ® No . Last date of occupancy: NA Date t5insp.doc•rev.7/2 612 01 8 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 352 Starboard Lane Property Address BELEN L CURRAN REVOCABLE TRUST. Owner Owner's Name information is required for every .Osteryille MA' 02655 6/7/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow,(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑. Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ) ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Po Y� 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t r 352 Starboard Lane 4 Property Address BELEN L CURRAN REVOCABLE TRUST Owner Owner's Name information is required for every Osterville MA 02655 6/7/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records,if any) Innovative/Alternative'technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the'I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: I Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1.5' feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet u Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight. No evidence of Ieakage.System vented through house vents. t5insp.doc•rev.7/262018 Tits 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form F Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 352 Starboard Lane Property Address HELEN L CURRAN REVOCABLE TRUST Owner Owner's Name i information is required for every Osterville MA 02655 6/7/20 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete -❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years ° Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 15.00 GI. Sludge depth: 5» Distance from top of sludge to bottom.of outlet tee or.baffle 46" 2- Scum thickness Distance from top,of scum to top of outlet tee or baffle 7 Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Measured Comments(on pumping recommendations, inlet and outlet tee or,baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump every two years.Inlet and outlet tees in place.No signs of leakage. t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 352 Starboard Lane Property Address BELEN L CURRAN REVOCABLE TRUST Owner Owner's Name - information is required for every Osteryille MA 02655 6/7/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ ether(€xplal^): J Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: - gallons Design Flow: gallons per day t5insp.doc+rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 11 of 18 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 352 Starboard Lane Property Address BELEN L CURRAN REVOCABLE TRUST Owner Owner's Name information is required for every Osterville "P MA 02655` 6/7/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level': Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is Ievel.Box has two outlet laterals with equal distribution.No signs of leakage. i t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 • 1 Commonwealth of Massachusetts ' Title 5 Official Inspection Form F! Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 352 Starboard Lane Property Address ` HELEN L CURRAN REVOCABLE TRUST Owner Owner's Name information is required for every Osterville MA 02655 6/7/20 page. Cityrrown State Zip Code Date of Inspection D. System Information.(cont.) 10. Pump Chamber.(locate on site plan): Pumps in working order: ❑ . Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.;: * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2/6'x4'•4' stone El leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches - number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of-Massachusetts Title 5- Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments v 352 Starboard Lane Property Address BELEN t CURRAN REVOCABLE TRUST Owner Owner's Name information is ; required for every Osterville MA 02655 6/7/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System(SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.No signs of hydraulic failure.Pits were dry at time of inspection. V II 12. Cesspools (cesspool'must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No. Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form in Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 352 Starboard Lane Property Address BELEN L CURRAN REVOCABLE TRUST Owner Owner's Name information is required for every OstervilW MA 02655 6/7/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note,condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection , Form FA Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 352 Starboard Lane Property Address BELEN L CURRAN REVOCABLE TRUST Owner Owner's Name information is required for every Osterville , MA 02655 6/7/20 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately ' F�a�t 1 of • gyp_.... ' � �� J 2 3/2020, c J Commonwealth of Massachusetts Title 5 Official Inspection Form FIA Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 352 Starboard Lane Property Address ]HELEN L CURRAN REVOCABLE TRUST Owner Owner's Name information is Osterville MA 02655 6/7/20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: As-Built ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used USGS observation well data.Used technical bulletin 92-0001 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 c Commonwealth of Massachusetts s Title 5 Official Inspection Form 1' Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 352 Starboard Lane Property Address BELEN L CURRAN REVOCABLE TRUST Owner Owner's Name information is required for every ..Osteryille MA 02655 6/7/20 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of:, / ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed& Dated and 1, 2, 3, or 4 checked, - ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding.Tank—Pumping,contract'attached For 14: Sketch of Sewage Disposal System'drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included P l I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 No.- ----- CGS --/®^ Fee-----L--/---------- BOARD OF HEALTH TOWN OF BARNSTABLE ZippCicat ion ArWell Construct ion Permit Application is he�.eb made for a permit to Construct ((mil, Alter ( ), or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel Owner Address % ?------------------ Installer — Driller Address Type of Building Dwelling— _---_----------------_____-- Other - Type of Building-=—_—__—____— No. of Persons-- -.-- Type of Well —______-_ _ Ca acit Purpose of Well.----__-_--__—_—___-- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health PrivgWVVe1111PPron Regulation - The undersigned further agrees not to place the well in operation un . 0 e has been issued by the Board of Health. S ned �_—_____ �`31-/odateApplication Approved B _ __--_— _' /o date Application Disapproved for the following reasons: date eJ Permit No. Issued—__�_--_________ /__—._�-----------_--------- date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate ®f Compliance THIS IS T�ERT kY, T� t the Ind*g*dual Well Constructed (Altered ( ), or Repaired ( ) by_____- �' �f�a _ --- --- ----- -- - - ---- ( installer at ,4' has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well /Protec ion Regulation as described in the application for Well Construction Permit No.(z.�Pl gIrled 33 -1-j0- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE - _ Inspector — ---____-- ` �� o-d C)-s Z_ No.--- ------------- Fee-------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Zpplication-for Melt Conaruction Permit Application is he.eb . made for a permit to Construct (41; Alter ( ), or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel _ / Owner n / Address Installer.— Driller Address —� Type of Building Dwellingr3'- =�-__ ` Other - Type of Building-----__--__— No. of Persons------ Type of Well CSec------- Capacity-- Purpose of Well ---- — Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Proteorion Regulation - The undersigned further agrees not to place the well in operation until' Cer 'i a/t f afn' 'ante has been issued by the Board of Health. S'gned date Application Approved U date Application Disapproved for the following reasons: i date _ Permit No. v" �-i----._`--/ !_�j� Issued __--_-_____-------- date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate Of Compliance THIS IS T�CERTJFY, Th4t the Individual Well Constructed(Altered ( ), or Repaired ( ) ----------._._.__---- Installer at___— � 2 �` �- -------------------------------------------------------------- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protec ion Regulation as described in the application for Well Construction Permit No.(Z-:� la Dated---3_AW3 0 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE Inspector BOARD OF HEALTH TOWN OF BARNSTABLE Vell Cootruct ion Permit No. Fee Permission is hereby granted to Construct ( , Alter ( ), or Repair ( an h�dividual W 11 at: ` No. 3S� s �b�> ti c' ��{ - ----------------------------------------- street as shown on the application for a Well Construction Permit No. Dated — 1 v- - ----------------_--- —�-�--- - �— -- - —� DATE 3 Board of Health Massachusetts Department of Environmental Protection Bureau of Resource Protection - Drinking Water Program BRP WS06e Residential Units (four units or fewer) Registration of Underground Discharges to Injection Wells ❑ Modification to an Existing UIC Registration (BRP WS-06e) El See Instructions UIC Registration Fee: check the appropriate category WS-06e. Residential Exemption (for four units or fewer) the following well types(typical residential activities) are exempt from a UIC registration fee: 5A7, 51D2, 5G30 &5X18 See Instructions Transaction Type Important: When filling out Registration: Initial-new registration ❑ Initial-existing registration ❑ Closure/Registration forms on the computer,use Modification: ❑ Change of owner/operator ❑ Change in or additional well/code(s) only the tab key to move your cursor-do not ❑ Change in location well(s) ❑ Change in#of discharge wells use the return key. For modifications(required) UIC Registration ID#issued by MassDEP in the original UIC Registration A. Residential Unit Information For modifications, enter only new or revised information. 14f1 c" L , CL r^tra ti Prop name/Private ame/Private Residence Company name(if different) --�) S z g +,.( L'0,,-J I 0 -:> t<c l)" \ke Property Street Address 1 City/Town V" A -n S ��tKS4 Water Supply: Public State Zip Code County Private Telephone Number Email(optional) See Instructions B. Owner/Operator Information For modifications, enter only new or revised information. /ifleh 1 . et� -3 Name of er Street Address S i`Vt _/ 4- City/Town State Zip Code Tr6 Telephone Number Email(optional) Ownership Type: PrivateX Private ❑ Commercial ❑ Nonprofit ❑ Other: specify Public: ❑ Local ❑ Regional ❑ State ❑ Federal ws06e.doc•rev.02/10 BRP WS06e-Residential Units•Page 1 of 5 `3 �//o Massachusetts Department of Environmental Protection L' Bureau of Resource Protection - Drinking Water Program BRP WS06e Residential Units (four units or fewer) Registration of Underground Discharges to Injection Wells [+� Modification to an Existing UIC Registration (BRP WS-06e) ❑ See Instructions C. Injection Well Information For modifications, enter only new or revised information. Registration: Individual or ❑ Area See Instructions- C.7 is I✓atL' �e I-,,r%n I f}etj ' Table at end Well Type Well Code See Instructions Well Construction (check all that apply) Number of wells: ❑ Drywell Dug well ❑ Cesspool ❑ Septic Tank ❑ Drainfield/Leachfield ❑ Trench Drain ❑ Other(describe): See Instructions Type of Discharge: Geothermal Heat Pump-open (5A7) ❑ Closed Loop Heat Pump (5A7) ❑ Groundwater Infiltration (5G30) ❑ Water Purification Discharge(5X18) ❑ Sump(5G30) ❑ Stormwater-roof drainage'(5D2) ❑ Stormwater-other drainage List water purification units discharging to Class V well: See Instructions #of entry oints to existing system #of entry points for proposed system Total#of entry points to system See Instructions V K P mr,W h A17p- /�60 F r l�ioH J - 144ec0 /Cr.�Sc Depth to water table(ft) Depth to bedrock(ft) Soil type(s)at site See Instructions Distance to nearest private drinking water well(within 1250 feet) MonthNear of well construction See Instructions Distance to nearest Public Water Supply(within 2500 feet) Name of nearest Public Water Supply' See Instructions i4�!p Z Gv P r 0?P :7 0 P I Distance to nearest etland or water body Distance to nearest septic system D. Operational Status See Instructions Well Operation Status: Designed, not yet constructed ❑ Under Construction ❑Active ❑ Temp. abandoned • ❑ Conversion to another well type ❑ Partial Closure/conversion to another well type (well code) ❑ Permanently abandoned/not reported previously ws06e.doc-rev.02/10 BRP WS06e-Residential Units•Page 2 of 5 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Drinking Water Program _.. - BRP WS06e Residential Units ._._.........._. (four units or fewer) Registration of Underground Discharges to Injection Wells [t� Modification to an Existing UIC Registration (BRP WS-06e) ❑ F. Affidavit The injection well(s)described above is used for placement or injection of fluids into the ground. I%we understand that this well is subject to inventory requirements and compliance with the regulations under the Underground Injection Control Program established pursuant to the Safe Drinking Water Act, P.L. 93-523, and amendments, and I/we hereby serve notice that the well is proposed or in service. /we agree: 1. That the well(s)described herein will not be used for discharges other than those described above; 2. That I/we will notify the MassDEP Drinking Water Program/UIC Program (on forms provided by the UIC program) if any of.the information (including Ownership, Location or Type of discharge) for the above well(s) changes, but before the change (30 days minimum notice on ownership/operator and 60 day notice on all other changes); 3. That I/we will notify the MassDEP Drinking Water Program/UIC Program (on forms provided by the UIC program—Pre-Closure Notification Form)when the above well(s) is no longer in use, but before abandonment and file a Post-Closure Notification Form within seven days of completing the closure with the UIC program. 4. That I/we will maintain financial responsibility for the well described above; and 5. That I/we will provide a sampling tap (approved by MassDEP) and allow sampling at the point of injection. I/We certify under penalty of law that I/we have personally examined and am familiar with the information submitted in this document and all attachments and based on my personal knowledge or inquiry of those individuals immediately responsible for obtaining the information, I/we believe the information is true, accurate, and complete. I/we am aware that there are significant penalties for submitting false information, including possible fines and imprisonment. 2 3 15 /Q Signature VDate o �Y T Printed name of prepares Position/Title ws06e.doc•rev.02/10 BRP WS06e-Residential Units•Page 4 of 5 FRA NEY508.539.86 fax 508.539.8665 MECHANICAL SERVICES, INC. rjfraney.com 56A Nicoletta's Way-Mashpee,MA 02649 March 19,2010 tp MDEP To whom it may concern We propose to install two wells at the property of Mrs.Helen ter at 352 Starboard Ln.Ostery lle MA.One to be a groundwater extractionwell and the second a groundwater recharge well.Both to be included.in an open loop geothermal heating and cooling system.Wells are marked an included property photograph.The maximum flow rate will be 30 gallons per minute.The well driller will be Fred Clifford of Clifford well drilling of Yarmouth MA.We intend to move foreword only upon permitting and a consequent favorable drawdown test,water test and soil condition. To the best of my knowledge,this plan conforms to all requirements for planning of such wells. Sincerely, Robert J.Franey Jr. Pres.,R.J. Franey Mechanical Services, Inc. 168HPA certified installer End. Well plan Plot plan Septic plan 0. 0 • t+ TyoWre conafvrt'able,,acre comformble" Town of Barnstable Geographic Information Systern March 18,2010 167027001 •420 187064 0448 187050 0 302 l f :r 188115 w 0 352 186048 0390 188114 0 348 188113 �330 t. DISCLAIMERS:This map is for planning purposes onty 11 is not adequate for legal Map.166 Parcel:115 a N boundary detarminauon or regulatory interpretation Enlargements beyond a scale of Selected Parcel W 1'-100 may not meet established may accuracy standards. The Va¢el lines on thi8 map Owner CURRAN,HELEN L Total Assessed Value$1844200 E are only graphlr,raprasaraalk>ns of Assessor's Ws parcels. They are nut true property CO-OwneC Acreage 4.31 acres Abutters twundanes and do not represent accurate relationships to physir:al features on the map Location 352 STARBOARD LANE $ such as bu,ldinq locations Buffer Aerial Photos Taken April 19,2008 Town of Barnstable Geographic Information System March 18,2010 144009 167021 167018 187016008 187014 •0 i6t i80 297 167016M2 2117 t 167026001 167019002 0100 0496 so 167016000 +H ' 187066 187025002 i 116�, 0464 J 167026002 187018011' 187019001 i 464 187018010 00 /104 - 187028001 i450 187046'• 1880133 167028 a : 0 431 167027002 0440 197054 0449 167020 y 144010 167020MI 0420 0416 167050 167028= i 392 167030 i409 .. 188115 i0 i 362 197028002 411399 188048 i 390 18�14 t88114 _ i� i 346 166047002 *379' 188037 108113 $96 0330 168088 166047001 i 291 0371 10805DO01 186006 $306 i 515 106100 0 341 188060002 i 280 test 07 1611111109 186050003 /88068 18800.9 i 50 $311 4t 28g i 277 i499 188018002 i 60 188061 t 1t36018001 166045002 188046001 9284 166057 1 ar 84 ,6 34 0291 168062 A 251 i i 230 DISCLAIMERS.This map ri for planning purposes only. It is nol adequate for legal Map.166 Parcel.115 N boundary determination or regula dory rnterpretalion Enlargements beyond a scale of Owner CURRAN.NELEN L Total Assessed Value:$1844200 Selected Parcel 1"-100'may not meet established map accuracy standards. The parcel lines on this map W E are only graphic representations of Assessor's tax parcels. They are not true property Co-owner' Acreage 4 31 acres Abutters boundaries and do not represent accurate relationships to physical features on the map Location 352 STARBOARD LANE such as budding locations. Buffer S Aerial Photos Taken April 19,2008 LEGEND IRC5911RE I PRE SSURE I/U10 il0f SANITARY SEAL °s snrc. BP.1 RtLEIF1EIR.1 vA[vt'Twr[s PRESSURE nofDR17ED Kit$IHSI ! TRIR90YCER ,g, OPTIONAL B' � RI eAu VALVE `t' PDn CDIRENT fIUEq 150104CASING �7 Y•��tvC riot nritR SEE NOTE It CIRCUIT . '[' ' [ORIPPWIER SEI fit '•'/ PUMP iINISNED GRADE GI ST�� Rln.Pq[CSUgC I'1`I. CHECK VI[VF PRFSSWE 'I CORIRO[VI[YE` _ 4AUSE __ 1EwERUWE --r SHIELDED ELECTRICAL r+,S HDPE RUOR _ w__UDF D1FFLlSIDN WELLrySCHEDIJLF 4'-6' (TRENCH WIRF.OR METAL CONDUIT I RETURN G!NE S {' FACILITY WALLiFOUNDATIDN DRILLED_DEPTHT3D� CASING LENGTH �'-'" --_ -•.-_ .-__ . _ 1 1/ VFD I CONSTANT PRESSURE� TTBD SANITARY SEAL C4QATRDLIEF 230VAC ',AM PS ! AMBIENT WATER DEPTH `TBD•,'. � SPLICE FORT BD RETURN DROP PIPE OPTIONAL 0' PUMP CABLE �L�Y `tEKTR! AHl ACCEPTANCE RISE LVL TBD EXTENDS 20'FEET CASING \\ RET.DROP PIPE LENGTH TBD; BELOW DRAW (SEE NOTE it \ ^ � .,.� DOWN LEVEL. \ V r FROM HEAT TBD J DIFF.SCREEN LENGTH FINISHED GRAOE. jJCT - - �i S � PUMPISI .� t's'PIf3E 1 , _ SUPPLY WELL SCHEDULE I --6' TrEvc `. 'PVC. 00 1 PIPE SIZES RETURN PITLESS SIZE. 1.5 1 _DRILiED UEPTHp F DISCONNECT gi RETURN PIPE SIZE T.5 i _CASING LENGTH TBp f A'STYROFOAM PRESSIREE !, /-PRESSURE SWITCH —SE 1 ON TRENCH Wi I / MAX CUT -75PS1 PUMP SET DEPTH TBD i PIFIPI ARE T ! AMBIENT WATER LVL TBD INGI / X PRESSURE TRANSDUCER HOPE R3AC8-f SET PSI 2s STABLE DRAW DOWN LVL r TBD t Y eT (SEE NOTE 61 r� SUPPLY LINE SUPPLY SCREEN LENGTH !TBD- JI � C 811 L" r� PIPE SIZES IN I' KEEP THIS PIPE / TO HEAT PUMPISI CMIt,_ 'T AS SHORT AS SEE SHEET:'smn i r;12 STEEL BOL r WELDED T'D STEEL SUPPLY PITLESS SIZE 1 5 POSSIBLE ✓rE1 L AS!NG 15R ELECTRICAL I w-^ SPIN DOWN FILTER BONDO 3L4ILD!d, I SUPPL1f P)PE SIZE MIS i 20-40MESHONLY IEIIN 1$ BEiGtW GRA9Ei ` ' NOTES: STEEL WASHER I, WELL HEAD ELEVATIONS TO BE WITHIN-2FEET OF EACH OTHER•(SEE STATE CODE I OCK WASiicR -^ — -- ' ! 1. ELECTRICAL BOND TO CASING PER INSET DETAIL. SCREEN DETAILS I 3, RISER ERY W. WILL HAVE IN-LINE CHECK VALVE �yT -.SUP SCREEN MAT'L O �TBD x , "s A. BACK PRESSURE VALVE REOUIRED FOR WELL SUP.SCREEN$L01'SIZE E r WITH MULTIPLE MEAT PUMPS {{ S. REIURN DROP PIPE SHOULD EXTEND 20'BELOW i r` N!iT mm=DIFF.SCREEN MAT'L i t MAX DRAW DOWN LEVEL. a K: 25 PSI AT THE HEAT PUMP IS THE OPTIMUM ALL CONTENT CONTAINED DIFF.SCREEN SLOT SIZE I w PRESSURE SETTING FOR MAXIMUM HEAT PUMP HEREIN IS ELECYRICAL.EARTH BOND 91 ELEC'TRICAi.-CONTRACTOR ' "�" "�•""-� SYSTEM EFFICIENCIES.E RELIABILITY.ANY PROPERTY OF WATER ENERGY MULTIPLE WATER USAGES LEG.DOMESTIC OR DISTRIBUTORS INC.:REPRODUCTION is 1. ELECTRIC EARTH BOND WIRE SIUBT ELECTRICAL IRRIGATIONIAPPkICA110NS MAY DICTATE WIRE PER NEC SECTION M DEPLOYMENT OF A,BOOSTER PUMP IN ORDER TO SrRICTLYPROHIBITED WITHOUT 3. EXOTDAISY CHAIC WELD N;00N MAINTAIN.MAXIMUM.NVAC SYSTEM EFFICIENCIES. EXPRESSED OR WRITTEN PERMISSION 7. DAISY CHAIN;DO NOT LOOP A. COMPLETELY ENCASE WITH WATER PROOF MASnc - FROM WED►OR THEIR OR AUTOMOTIVE SPRAT UNDERCOATING. REPRESENTATIVES_ RESIDENTIAL SUPPLY&DIFFUSION I RE-INJECTION PROJECT: APPLICATION REV} Water Energy DiS>tribut o S Inc ®2 s ?I $ Concept Preliminary ., Starwood Drive Hampstead NH 03841 R-3 DESIGNED BY.`: }gp PATE •tiy23lOS`DO NOT SCALE STATE 'tgA (603)329-8122 www.northeastgeo.com SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1'W (_s1\•' o Owner:. i), Date of Inspection; (7� SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' C 13- l3l DEPTH TO GROUNDWATER Depth to groundwater: feet method of determination or approximation: revised 6/is/9s1 9 �v No.-------------------- Fee-------- ----------- BOARD OF HEALTH TOWN OF BARNSTABLE ApplicationArVelr Conotruction Permit Application is here Lb �nad_e for permit to Construct (_ , Alter ( ), or Repair ) mdiv ell at: Location — Address t Assessors Map and Parcel --------------- -- --------------R-ed-----�1- Qr ------- -- --------- Installer — Driller Address Type of Building Dwelling-------------------------------------------------------------- Other - Type of Building ------- No. of Persons--------------------------____—_____________ Type of Well�--C o S _ - ----- --- YP Capacity---- - Purpose of Well------------rf G l ------------- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private W Prote ion Regulation - The undersigned further agrees not to place the well in operation un ' a r ' e ance has been issued by the Board of Health. Signe - - -�} - — 0 —adat 5 -- - Application Approved By - - -- -_ Application Disapproved for the following rea s:--------- --------==--------------------------------------------------------- ----------- -= _-- ---- -- - - - - ------------------------------------- ---- - - - date ----------- -- — ------- I 7LI r Permit No. --- ------- -- ---------- Issued--------- - - date BOARD OF HEALTH TOWN OF BARNSTABLE QCertifitate ®f Compliance THIS IS TO CERTIFY, That the (Individual W 11 Co, truct (✓), Altered ( ), or Repaired ( ) bY------------ ---- -------------------1'_re-CL-51_l0-�n_�t^ --- - - —- - - -- Installer at---------------_ 5a--.57 a c b o (_ &°7--__ 51e n u dli�-------------------- ---------------------------- has been installed in accordance with the provisions of the Town of Barnstable B d o alt e Well Protection Regulation as described in the application for Well Construction Permit N . v- - tied------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE - — - -- Inspector----------------------------- - -- - ------------ -------------��----�- - 6, '! No.-------------------- Fee--------; ----------- �( BOARD OF HEALTH TOWN OF BARNSTABLE 01pprication,forVell Constructionpermit Application is hereby m de for permit to Construct ( Alter ( ), or Repair ( ) fi indiv'd ell,at: Location — Address t Assessors Map and Parcel "------------=-------�_UlG --------- --- ---------------------------dress ----------------- ---------------- -----C/j_7'1q0r_ Installer — Driller Address I� Type of Building Dwelling-------------------------------------- ------------------ - I Other - Type of Building ------ No. of Persons------------------------------ aced nn Type of Well--- -- - Purpose of Well-------- Agreement: F The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The 'i Town of Barnstable Board of Health Private WOVProtec ion Regulation - The undersigned further agrees not to place the well in operation un ' a r cate C fiance has been issued by the Board of Health. Signe -- G' - — C } 'Application Approved By- ( date - ------- 4 Application Disapproved for the following rea s:--------------=- ------------ r /�! V % -- i_ / /OCJ date � Permit No. --- ------------ Issued--------�--�------------------------------------------ i date -- ---- ---------- ----------------------- ------------------------------------------ BOARD OF HEALTH i TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Cgotruc (Altered ( ), or Repaired---------------- r� -— OL' -------------------------------------------------------------------------------- Installer % at----------------cJ�J --_5� r- _r_ -- - - -� �- �` l e--------------------- - -------------------------- has been installed in accordance with the provisions of the Town of Barnstablek f alt ate Well Protection Regulation as described in the application for Well Construction Permit N - - !D ted------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. jDATE-------------� -��-------1 Inspector--------------------------------------------------------------------------- --_---------------------------- �- ---------- ------ BOARD OF HEALTH TOWN OF BARNSTABLE ell ConstructionVermit rV No. - ---- -------- Fee----1--------- �red f Permission is hereby granted----------___�#0-��---------------------------------------------------------------------------- to Construct ( b'1, Alter ), o Repair ( ) an Individual el at: No. - - �� - ljG r� ,—-� --------------�� - - ------- ------------------------------------------- Street as shown on thf application for a,yaJell Construction Permit No. ,- --- -- Dated-- - --------------------------------------------- -----------r B--- - �,{� — oard'o; Health DATE-- - -- -- --— Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of s , Environmental Protection William F.Weld Governor Trudy Cole c;�s Secretary,EOEA ® � "'A liZ, 4 David B. Struhs Commissioner _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A . CERTIFICATION Property Address: 0-Q,,p 1J J�Address of Owner: Date of Inspection:. (If different) Name of Inspector:--ZcQ�.-----0�. Company Name, Address an elephone Number." M,0.1-4 e eP\sC- (3A)'c1.,P,. i�- CERTIFICATION STATEMENT I certify that I have personally inspected't.ie sewage disposal system at this address and that the information.reported below is true, accurate and complete as of the time inspection."`The inspection was performed based on my training and experience in the,proper function and •` Y maintenance of on site se ge disposal systems. The system; __ • .? _ Passes Conditionally Passes . _ Needs Further Evaluation By the local Approving Authority .t Fails f t Inspector's Simre.• /- Date: 7 L �+ (� K The System Inspector shall su mit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this k inspection. If the system is a shared system or has a design flow.of 10,000 gpd or greater, the inspector and.the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. ;: The original should be sent tv me system owner and copies sent to the buyer, if applicable and the approving authority. )F� x � r c. INSPECTION SUMMARY: - Check A, B, C, or D; A SYSTEM PASSES: ' i t 01. I have not found any information which indicates that the system violates any,of the failure criteria as defined in 310 CMR 15.303 Any failure criteria not evaluated are indicated below. t#4 B)'SYSTEM CONDITIONALLY PASSES: ` : ,; r1 " One'or.more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y,N, or ND). Describe basis of determination in all instances. If"not determined", explain`why not);: The septic tank is metal, cracked, structurally unsound, shows substantial`infiltration or exfiltration;or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as s' . - 3 approved by the Board of Health. =r (revised 8/25/95) One Winter Street a Boston,Massachusetts 02108 a FAX(617)5WI049 a Telephone(617)292 �A,Printed on Recycled Paper - z SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:3 J'Y 2 Ltfrl � lc <"1`•��— Owner: Date of Inspections B]SYSTEM CONDITIONALLY PASSES.(continued). _ 'Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or.due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board_ of Health): broken pipes)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection.if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed F 1 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: 1 Conditions exist which require'further evaluation by the Board of Health in order to determine if the system is failing to protect the. public health, safety and.the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH.WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or pricy. is'within 50 feet of a bordering vegetated wetland or a salt marsh. e 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING 1N A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ I he wstem has a Septic.tanK anu soli ausurptiun sybiem and is within i ail ieci iu a su 16Uz Vraici SUPPI-) Gi tribuiar)' to a surface water supply. -The system ha, a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a,septic tank and soil absorption system and is within.50 feet of a private water supply well. _ The System has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless,a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is.' free from pollution from'that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5. ppm• D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool: s _ Discharge or pondingof effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/55) 2. SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3 <- �� `'� �- ^"t PCs} �._�_,;. 0 1 Owner: Date of Inspection D] SYSTEM FAILS (continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth.in'cesspooI is less than 6" below invert or available volume is less than 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). z Number of times pumped i _ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of.a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ` Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or.,privy is less than 100 feet but greater than 50 feet from.a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because-one or more of the following conditions exist: the system.is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone.11 of a public water suppiy well! The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 600. Please consult the local regional office of the Department for further information. ,lrevised 8/15/95) 3 SUBSURFACE'SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART B r - CHECKLIST Property Address: J C .�r-t✓�,b�1,r-c �--'.�•E'er . C7 ��- t Owner: LAJ e' 11 It, _ Date of Inspection: Check if the following have been done: a c/ Pumping information was requested of the owner, occupant, and Board of Health.. -/None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates ring that period. Large volumes of water have not been introduced into the system recently or as part of this inspection _As built plans have been'obtained and examined. Note if they are not available with N/A. ,4:, . 3 e facility or dwelling was'-inspected for signs of sewage back-up. _The system does not.receive non-sanitary or industrial waste flowb The site was inspected for signs of breakout. z �r )All system components, excluding the Soil Absorption System, have been.located on the site. sti he septic tank manholes were uncovered, opened, and the interior of the septic tank,was inspected for V T ndrtion of baffles;orb ` tees, material of construction' dimensions, depth of liquid, depth of sludge, depth of scum. . I ' z t,. LThe size and location of the Soil Absorption System on the site has been determined based on existing information,or ; proximated'by non-intrusive methods. } 1 _The facility o ,r,e ;zindl occupants, if different from owner) were provided,with information on the proper maintenance of Sub Surface Disposal System. s{ : y x.. 5 % c a ��C} *. of - ,i.•`^ .. - _ a - j�+••�•y�r�4T �j hex'+ �s (revised 8/15/95) 4 d�Yt a 5 L kt SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 1 SYSTEM'INFORMATION Property Address: S j t57&,rY�D�-r- '-�• `�'� `�� Owner: Lju-r' •1 c� Date of Inspections FLOW.CONDITIONS .' RESIDENTIAL ... Design flow: gallons <r5 '":'fix Number of bedrooms: Number of current residents:_ �� t . Garbage grinder (yes or no):_ it 4 t' Laundry connected to system(yes or no):_ Seasonal use (yes or no):_ 3 ` Water meter readings, if available: { 1i} Last date of occupancy; F��' COMMERCIAUINDUSTRIAL•. Type of establishment: Design flow:_—gallons/day �ii Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5.system: (yes or no)_ Water meter readings, if available: Last date of occupancy: �..< p � A $'X,`f r, OTHER: (Describe) r at Last date of occupancy: :4y _ _ 1 its"; � i•^S,e`"§X LlI�",. GENERAL INFORMATION ! •k ' PUMPING RECORD_ S and source of information: tt. "k) System pumped as part of inspection:(yes or no)_ If yes,volume pumped: "gallons Reason for pumping: ;,TYPE401` SYSTEM ...,. s F Septic tank/distribution box/sod absorption system Single cesspool. r .t ' Overflow cesspool . Privy f t ` Shared system (yes or no) (if yes, attach previous inspection records,:if any) { Other(explain) a.•t..`k- ��i -. ~;Ft q. rL+ `ntT'�' ,yrt. '�..} APPROXIMATE,.AGE of all components, date installed (if known).and source of information: "- } V. Sewage odors detected when arriving at the site: (yes or no) dr ; (revised 6/15/95) -59 'AIN V. ) r Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) - \ Q �Yv DV` S l i 1 Property ert Address:��c�--S��.++__�pc.`—cQ Owner: Date of Inspection: f ° SEPTIC TANK:— � x c ut (locate on site plan) - x ' ' � '' '' x" Depth below grade: Material of construction: —concrete!—metal FRP—other(explain) Dimensions Sludge'depth Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: } r Distance from top of scum to top of outlet tee or baffle: u� Distance from bottom of scum to bottpm of outlet tee or baffle: F F (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) x GREASE TRAP: (locate on site plan) k Depth belov� grade: Material of construction: concrete _metal _FRP—other(explain) _ Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: �'` $ Wiz'° �t� t Clistance from bottom r`� sn!� t� hottorr of outlet tee or battle' +: sF ` s .. .: .. .. � �"f'` �.<eft r•Y�° f f ;.� � t 4 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to;outlet Invert, structural integrity, evidence of leaks e, etc.) t AWi � t eg%, A `°v rkk r t 'e a°ri r k ,., s '(-�'. .g xj• y .S'sCWy,rS i h ••,�g�S�'y.�##�r� i F - � ert {y� / .� �x �# �y� ��r^-+M 3>� x i' b� 'H. .�.x y � - d { K�' C. .•�f iy �( f L {�� r _. � } t`�., ..• � ��1� fi�F�ti��'s�'"'��,"�'+"kss'4 r7,y a �� 6y � S. • l Yu 3 r ,r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION (continued) Property Address: Jc�- Owner: l V ��---- ,' Date of Inspection: ' 'TIGHT OR HOLDING TANK:�I (locate on site plan) Depth below grade: iw# material of construction: _concrete _metal _FRP_other(explain) Dimensions: Capacity: t atIons Design flow: gallons/day Alarm level: s. u Comments: (condition of inlet tee, condition of alarm and float,switches, etc.) }; DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: mote ii level and distributic,t- ,; eyed;, e�;dence of solidi ccar�o�er, evidence of leakage into or out of box, etc.) t PUMP CHAMBER: (locate.on;site plan) w ` ' ..i -• ... �}TMt.K scN=+rM1«W, .r...F�yk J.�, f Pumps in working order.(yes or no) a ` Comments: ' tar t x, (note condition of pump chamber,.condition of pumps and appurtenances, etc.) } tY `' lsevised �8/15/95) f ,y k SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C SYSTEM INFORMATION (continued). Property Address: v5t'�a.Ybc�c�r Owner: Date of Inspection: G }4 SOIL ABSORPTION SYSTEM (SAS):_ (locate on.site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) '}f'` If not determined to be present,-explain: ) Type: leaching pits, number:_ '3V leaching chambers, number._ --- „� leaching galleries, number. leaching trenches, number,length: leaching fields, number, dimensions: ) '" � '•'{^° overflow cesspool, numbeG Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) ' ''" �t CESSPOOLS: (locate on site plan) Number and configuration. Depth-top of liquid.to inlet.invert: fi.r"' Depth of solids layer: , Depth of scum layer: Dimensions of cesspool: Materials of construction: c ° s Indication of groundwate,'. - inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic.failure, level of ponding, condition of vegetation, etc.) { 4ti ti . - ..., s'.`°ki' F''` Z.F.* sC•„' ;. PRIVY:* • � 5 .gt cr T 9-te (locate plan) R Dimensions Materials of construction A ` Depth;of_solids: ., .• w Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) t s ¢,*a w Yf t 1 i f� (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '.PART C SYSTEM INFORMATION (continued) Property Address: Owner: \kie-N1 O— Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' L %(� Al s .DEPTH TO GROUNDWATER , T Depth to groundwater.' feet ` method of determination or approximation:. M S All. = k s -`(revised 8/15/95) 9 x n o y 4 ra, nt}k • - - '9i 6 `sue.. TOWN OF BARNSTABLE LOCATION �s� ff�� o�trr� SEWAGE # !' 5—/U 6 �, VILLAGE 'J' ey"v l 1 Q ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. J W C A SEPTIC TANK CAPACITY I�� n LEACHING FACILITY:(type) P L 0 0 (size) I� NO: OF BEDROOMS WELL.OR BLI WATER /,dam BUILDER OR OWNER 1 DATE PERMIT ISSUED: do c �� DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No /w 10 9 gel .o - No.._. ..._....... F>s. . ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ?J! ...0---ApplirFatilan fear Uhipas al Workii Ton.strnrtinn 1hruat Application is hereby made for a Permit to Construct (A or Repair ( ) an Individual Sewage Disposal System at: .......... ----------------------------------------------- Location-Address t No. 0 al Owner Address a ��.� a.-c--.q................••---..................... ----•--•_-- •..........------•......__............_..----•-------------- -- -- Installer Address Type of Building Size Lot/lbj. d_�_Sq. feet V Dwelling—No. of Bedrooms.....................iK...................Expansion Attic ( ) Garbage Grinder Other—T e of Building No. of persons.................•..._______ Showers a YP g -------•-------------------- P ( )._— Cafeteria-(----)- 04 Other fixtures -------•---------------------------------------------------------------•--------------...-----------------•......-- W Design Flow..........1 _ gallons per person per day. Total daily flow_______l14l�� _____ __________ Ions. g 7'.......... g P P P Y Y . WSeptic Tank—Liquid capacityl llons Length................ Width.............--- Diameter---------------- Depth................ x Disposal Trench—No. .................... Width ........ Total Length.................X Total leaching area....................sq. ft. Seepage Pit No......... ....... Diameter...._f�t�..... Depth below inlet.M��....... Total leaching-area.Z.4�1.sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results A Performed bY.......................................................................... Date........................................ Test Pit No. 1 ...minutes per inch Depth of Test Pit.../J";4...._. Depth to ground water._.a�'I- ___. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ---------------------------------- ••. .... ............ ............ ----------------,- ---------•-----------•--------•= O Description of Soil-------------------•0---=�-�®..... b o ,Q -H'� � ®� /-•---------- xb ._-.�. �Z ....._••••• ... � -------•-•-- w --------------------------------------------------------------------------------------------------------------------------------------------------------------------------••------••-••-••------••. V Nature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed 'Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beea by the and of health. igned•-•• ----- �� ..._ .� Date �- Application Approved BY . _........---••--•-.....---•-- -------.................. ......... �'� Date Application Disapproved for the f ollo ng reasons:---•---------------------------------------------------------------------------------------------•------------- --•--------••--•••••--•-....--•••-----•-......-•-•---•-•-•-••-••-•----•----------------------•---------------•-••---•-••••-•----•--------------•-•-•--•--•--•-•--•••----------•-•--------•--••--..._.._. Date PermitNo.......................................................- Issued....................................................... Date t; •Z� \ *. THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH . ........ ........ y :,.-..................... Appliratiun`for Disposal Works Tonstrurtiun prrmit . Application is hereby made for a Permit to Construct ( O or Repair .( ) an Individual Sewage Disposal ` System lit: .:.............__......- --•--......---------•-•------•--•--•--•--....•-•---........•..•..... ..••••------........_._...........-•------•---•-• --•---.....................-----.....--- / y 4otoonn AddressY. Owner Address � a Installer Address Type of Building - Size feet U Dwelling—No. of Bedrooms.................... ....................Expansion Attic ( ) Garbage Grinder (X) p4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ................................ . Design Flow......._la.7 :.:Y_..._•.....gallons per person per day. Total daily flow------i4l'.10.........................gallons. W �.. W Septic Tank—Liquid capacity.:_:_..._._�� _gallons Length................ Width................ Diameter-------......... Depth................ _ x Disposal Trench—No..................... Width•_•_. ....... Total Length.................... Total leaching area.........._.........sq. ft. Seepage Pit No..................... Diameter....f: ..... Depth below inletMt-��.._.....•.. Total leaching areaZ1S.',_.Lsq. ft. Z Other Distribution box ( ) Dosing tank ( ) a _ Performed by ,, --------- Date a Percolation Pit No.Results minutes per inch ' Depth of Test Pit_-,': Depth to ground water------------------------ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Description of Soil....................... ......... . 8 w - - UNature of Repairs or Alterations—Answer when applicable............................................................................................... --------•-------------••----•---........------•--•-••------•----------.........-----.....---................------------------------......--.....--------•----------•----------------....---------•-•••. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee d by tbz4oard of health. igned . ......................... Application'Approved BY fit,---: .. .. Application Disapproved for the f olio ng reasons----------------•---------------•------------------------------------------•-----.............-•••-•---- .: . Date PermitNo......................................................... Issued-.--------...... Date THE COMMONWEALTH OF MASSACHUSETTS _. BOARD OF HEALTH ..........................................OF..................................................................................... Currtifirtttr of Tomplionrr THIS IS TO CERTIFY, That the In&l idual Sewage Disposal System constructed ( ) or Repaired ( ) by -------------------••-•...----•-•-•---........•---..._..........•----.._.__' .......----•-------••--•-•-•-------...........----------•-----..............----........._•--•-............---- Installer at-. ••-•-••-----••••-•-•-••••-••................••-----------•--•-----------•----•---••--•--•••••••••-••----•--•-----............--•...--••------•-•••-•••••--••-•••-....-----•--••---•-•--• ' has'�been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE,ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............... ............................. Inspector...... -- ...... ------. b THE COMMONWEALTH OF MASSACHUSETTS M BOARD OF HEALTH No.................... T�b .......................................... FEE........................ Disposal Works T-Palustrurtion Vprrmit Permissionis hereby granted.............................................................................................................................................. to Construct Re air an Indivi ual Sev�ra D' sal S st� Je ( ) P P Y atNo......................................... .......`✓`l :_......... ------ ---1 •-------•--- Street' as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... th DATE....................4_1...................................................... FORM 1255 A. M. SULKIN, INC.. BOSTON t ri LIU13 od H d•j. � • � � Jiff^ � � ; r . _.�..o •�u •d I w. CY 4 30 1- f V. y.9n lac. v. .:SSb2#Q I1SIX3ool r , � � OO2 j• `_ �✓ Sb3MOIJOI 1 /. �. SjT -130�Nd 991 ddW � . SdOSS3SSd 000'S2 t TIVOS dyn snot . •, `, �eye s OG N 08 o.. c. � t - TOP OF FOUNDATION _ � 1 CONCRETE COVER EL /` y` •� a 1f`u_ _ ---__ _ ,, r CONCRETE COVERS *L - r- -�- ° 4„ MAX 12 CAST IRON " . • \ \\ � 12"MAX OR SCHEDULE 40 4"SCHEDULE 40 PVC (ONLY) PVC PIPE PIPE - MIN \� LEACH PITCH 1/4'PER FT PITCH 1/4••PER FT PIT PRECAST —INVERT - a LEACHING \ \ \ ' b 4P e EL t'` INVERT INVERT a �w �•. PIT OR /V� a INVERT SEPTIC TANK EL ..': = Z BOX EL` >= EOUIV Q X _ e EL GAL . IELERT INVERT w W •• T 3/4"TO 11/2 �� • \ \ _ r EL iy./o 0 WASHED STONE w 20 _A -_ PROF 1 L E OF GROUND WATER TABLE o a `�,� `__��I ,/f •w^� �, �� 11 '� SEWAGE DISPOSAL SYSTEM ' �'��, , T: ,j Cep �2 �-• � � ,h'� NO SCALE SOIL LOG WITNESSED BY DATE ' `` TIME �oN G/fFoRrj .r ,C? BOARD OF HEALTH TEST HOt E I TEST HOLE 2 C. �Ez��.. ENGINEER e ,;'`►�' DESIGN DATA NUMBER OF BEDROOMS 1 TOTAL ESTIMATED FLOW 1C GALLONS/DAY A i% I BOTTOM LEACHING AREA SQ.FT. /PIT,' i - �I SIDE LEACHING AREA SQ.FT./ PIT/ GARBAGE DISPOSAL y445. (50 % AREA INCREASE ) TOTAL LEACHING AREA G/S! SQ.FT PERCOLATION RATE Wh!h! i W. MIN / I NCH LEACHING AREA PER PERCOLATION RATE SQ.FT./G. WATER ENCOUNTERED NUMBER OF LEACHING PITS 4 PiT5. W/77-�. APPROVED BOARD OF HEALTH �'� •FE2'T ,OF -%D�nN d!� ABC, S/DES I 1 DATE AGENT OR INSPECTOR zo I Td?/9L I 6C L!.- f n y No. l t�toTC 1 � i • J�a� S4 N.T AP'iP f ` ` PETITIONER th ol y j , G / I / U rL- vece z I � ti �19 _ /v074-- 424w►i,1774Ws f9-/ . •�,, - , r, ,1 :yam, R�